Provider Demographics
NPI:1124668132
Name:BULLOCK, TRACI A (CRNP)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:A
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 FITNESS WAY STE 1200
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35611-2492
Mailing Address - Country:US
Mailing Address - Phone:256-236-0636
Mailing Address - Fax:256-232-1281
Practice Address - Street 1:101 FITNESS WAY STE 1200
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-2492
Practice Address - Country:US
Practice Address - Phone:256-236-0636
Practice Address - Fax:256-232-1281
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALI28281363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALI128481OtherRN LICENSE